Healthcare Provider Details

I. General information

NPI: 1174143994
Provider Name (Legal Business Name): AMANDA YUAN GU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 TRAFALGAR SQ
TRAFALGAR IN
46181-9515
US

IV. Provider business mailing address

14 TRAFALGAR SQ
TRAFALGAR IN
46181-9515
US

V. Phone/Fax

Practice location:
  • Phone: 317-412-9190
  • Fax:
Mailing address:
  • Phone: 317-412-9190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01089396A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: